1
Q
What types of study designs can be used to evaluate the affect of diet on cancer?
A
- cross-sectional observational studies of different countries diet and cancer risk
- cross-sectional migrant studies
2
Q
How much of cancer is preventable by appropriate food, nutrition, physical activity, and body fatness?
A
- total for all cancers = 26% in UK
- but obviously different for different cancer sites = as high as 75% for oesophageal cancer in the UK
3
Q
Which exposures are most attributable to cancer cases in the UK?
A
- tobacco 19.4%
- diet 9.2%
- overweight and obese 5.5%
- alcohol 4%
4
Q
What are the different types of population research?
A
Descriptive
- survey
- case report
- case series
Analytic
- experimental (trials)
- observational (cohort, case-control)
5
Q
What are the problems with using case-control designs to study diet?
A
- variety of accuracy in recall of diet between cases and controls (cases are more motivated to accurately report exposures than controls)
- possible early impact of disease on diet (pre-symptomatic disease state may have influenced dietary choices - studies often disregard 1-2years before diagnosis)
- measurement of diet is difficult and often ambiguous
- bias
- confounding
6
Q
What are the problems with using cohort designs to study diet?
A
- hard to accurately measure diet in large cohorts
- difficult to maintain follow-up over the long periods of time that are necessary to power the study
- bias
- confounding
7
Q
Why is it difficult to accurately measure and study diet?
A
- random error (diet varies and people may make mistakes in their reporting)
- homogeneity of exposure (at a population level, e.g. UK students, diet is actually largely the same)
- bias
- confounding
8
Q
How can you measure diet?
A
- food disappearance data
- household surveys
- individual surveys
- 24 hour recall
- food frequency (FFQ)
- diet diary
- biomarkers
9
Q
What are the pros and cons of using food frequency questionnaires in studying the effects of diet on health?
A
Pros:
- captures usual diet
- less work to code of compute
Cons:
- doesn’t record actual diet as eaten
- overestimates fruit and veg
- poor measure of energy intake
- less flexible
10
Q
What are the pros and cons of using diet diaries in studying the effects of diet on health?
A
Pros:
- records diet as eaten (over a limited period)
- more flexible
- better estimate of energy and absolute intake
Cons:
- requires effort to complete
- expensive and time-consuming to code
- alters diet when the diary is being completed
11
Q
What are the main associations between oesophageal cancer and diet?
A
Increased risk:
- Convincing evidence for alcohol (squamous) and obesity (adenocarcinoma)
12
Q
What are the main associations between stomach cancer and diet?
A
Increased risk:
- Probable evidence for body fatness, alcohol, salted preserved food, meats and pickles
13
Q
What are the main associations between pancreatic cancer and diet?
A
Increased risk:
- Convincing evidence for obesity
- Probable evidence for height
14
Q
What are the main associations between hepatic cancer and diet?
A
Increased risk:
- Convincing evidence for aflatoxin contamination, alcohol, body fatness
Decreased risk:
- Probable evidence for coffee
15
Q
What are the main associations between colorectal cancer and diet?
A
Increasing risk:
- Convincing evidence for processed meat, alcohol, body fatness, central obesity, height
- Probable evidence for red meat
Decreased risk:
- Convincing evidence for more physical activity
- Probable evidence for dietary fibre, wholegrain, dairy, calcium supplementation
16
Q
What are the main associations between pre-menopausal breast cancer and diet?
A
Increased risk:
- Convincing evidence for height
- Probable evidence for alcohol and high birthweight
Decreased risk:
- Probable evidence for more physical exercise, overweight/obesity, lactation
17
Q
What are the main associations between post-menopausal cancer and diet?
A
Increased risk:
- Convincing evidence for alcohol, body fatness, height, adult weight gain, central obesity
Decreased risk:
- Probable evidence for more physical activity, body fatness in young adulthood, lactation
18
Q
What are the main associations between lung cancer and diet?
A
Increased risk:
- Convincing risk for arsenic in drinking water, high dose beta-carotene supplementation
19
Q
What are the main associations between prostate cancer and diet?
A
Increased risk:
- Probable evidence for body fatness, height
20
Q
What are the main associations between renal cancer and diet?
A
Increased risk:
- Convincing evidence for overweight
- Probable evidence for adult height
Decreased risk:
- Probable evidence for alcohol
21
Q
What are the main associations between endometrial cancer and diet?
A
Increased risk:
- Convincing evidence for overweight/obesity
- Probable evidence for glycemic load
Decreased risk:
- Probable evidence for physical activity and coffee
22
Q
Why “five a day” ?
A
- evidence that less than 200g/day fruit/veg is associated with increased cancer risk
- little benefit observed beyond 400g/day
- average portion size = 80g, 400g/80g = 5 portions
- however continuing benefit shown for increased fruit/beg intake in reducing CVD risk
23
Q
What are the health promotion messages relevant to cancer?
A
- increase levels of physical exercise
- don’t put on weight in adulthood
- aim for a BMI between 18-25
- maintain safe levels of alcohol intake
- increase fruit/veg intake to at least 400g/day
- limit intake of preserved and red meat
24
Q
What are clinical decision support systems?
A
- systems designed to aid clinical decision making, not replace it
- provide clinicians with patient-specific assessments or recommendations to aid clinical decision making
- different types available for different purposes:
- computerises (including apps)
- paper based
- reminder systems/prompts
25
Outline the potential uses of reminder systems:
- screening
- vaccination
- testing
- medication use
- identification of risky behaviour
- e.g. recall system, allergy pop-ups, reminders to consent for online services
26
Give examples of clinical decision support systems:
- reminder systems
- decision systems (diagnoses and treatment)
- prescribing systems
- condition management
27
What are decision systems (for diagnoses and treatment)?
- model individual patient data against epidemiological data (which may be held in a computer database)
- often match patient signs and symptoms to database to provide hypotheses or estimates of probability of different potential diagnoses
- e.g. Ottawa ankle rules
28
What help can prescribing systems provide?
- advice on drug dosage
- advice on drugs to prescribe
- highlighting potential drug interactions
29
What four elements improve clinical practice when using decision support?
1. providing decision support as part of the clinician workflow
2. providing recommendations for management (not just patient assessments)
3. providing decision support when and where decision making was happening
4. computer-based decision support
30
What barriers are there to successful use of CDSS?
- earlier negative experience of IT
- potential harm to doctor-patient relationship and reduction in shared decision making
- obscured responsibility (loss of clinician/patient autonomy or clinical reasoning)
- reminders seem to increase workload
31
What facilitators are there for successful use of CDSS?
- self-control of CDSS
| - if the clinician can notice the help in practice
32
What are the aims of patient decision aids?
Enable patients to:
- understand probable outcomes of options, by providing information relevant to the decision
- consider the personal value they place on benefits versus harms, by clarifying preferences
- feel supported in decision making
- move through the steps in making a decision
- participate in deciding about their healthcare
33
What are patient decision aids?
Interventions designed to help people make specific and deliberative choices among options (including the status quo) by providing (at the minimum) information on the options and outcomes relevant to a persons health status
34
What are the barriers to brief interventions for harmful alcohol use in primary care?
- time
- attitudes of staff
- potential impacts on patient relationship
- skills and training
- links to community support services
- patient reluctance to disclose problem drinking
- patient denial of problem drinking
35
What are the societal impacts of alcohol consumption in England?
- fifth highest risk factor for ill-health and reduced life expectancy
- >1 million hospital admissions
- £3billion cost to NHS
- 23,000 deaths attributable wholly or partly to alcohol
36
What are the trends in alcohol consumption, affordability, and consequences since the 1980s?
- consumption of most types of alcohol has gone up
- affordability has gone up
- alcohol related deaths have gone up
37
Why is alcohol considered to be a drug?
- psychoactive
- CNS depressant
- cause of harm through intoxication, toxicity and addiction
- massive disease burden
38
Why do some people not consider alcohol to be a drug?
- big industry with vested interests
| - culture
39
What are the two levels of resource allocation decisions?
- macro level (strategic, societal)
| - micro level (clinical)
40
Give arguments against age-based rationing of healthcare:
- devalues the status of older people
- caters to the values of a youth-orientated culture in which ageism is prevalent
- may foster a trend for decreasing respect towards the elderly
41
Explain the fair innings argument for age-based rationing in healthcare:
- suggests greater equity could be achieved if older people were to forgo some health services in favour of the young
- suggests older people have already had a fun life and younger people have not
- argues healthcare should be distributed more to younger people to equalise "lifetime experiences of health"
42
Give an argument for and against micro-level resource allocation based on age
For: generally older people are less likely to be responsive to treatment
Against: age alone is not a good predictor of prognosis / likelihood of complications
43
What are the nine protected characteristics of The Equality Act (2010)?
- age
- race
- sex
- gender reassignment status
- disability
- religion or belief
- sexual orientation
- marriage and civil partnership status
- pregnancy and maternity
44
What is direct age discrimination?
- when a direct difference in treatment based on age cannot be justified
- a direct difference in treatment is a situation in which one person is treated differently to another in a comparable situation, based purely on age
45
What is indirect age discrimination?
- when seemingly neutral provision, measure or practice has harmful repercussions on a person, or group of persons
46
What are QALYs? and how are they calculated?
- quality adjusted life years
- involved assigning a utility value (0-1) to a state of health and then multiplying that value by the number of years expected to be lived In that state
- e.g. 5 years at 0.5 QALY points = 2.5 QALYs
- e.g. 5 years at 0.8 QALY points = 4 QALYs
47
What type of healthcare activity generates a positive amount of QALYs?
- beneficial
48
What type of healthcare activity has the lowest possible cost per QALY?
- efficient
49
What type of healthcare activity has a low cost per QALY?
- high priority
50
What type of healthcare activity has a high cost per QALY?
- low priority
51
What are the arguments for using QALY-based assessments?
- address primary purpose of healthcare (maximising welfare = combination of quality and quantity of life)
- seems to be motivated at the individual patient level
- usable in practice
- widely utilised
52
What are the arguments against using QALY-based assessments?
```
procedural objections:
- difficult to measure
- difficult to control/eradicate bias
some QALY-based assessments are unjust:
- double-jeopardy objection
- end of life care loses out
- favours life years over individual lives
```
53
Are QALY-based assessments ageist?
- yes because they discriminate against older people
| - no because they do not aim to discriminate against older people
54
What is efficiency?
Obtaining the greatest output for a given set of resources
55
What is technical efficiency?
- Maximisation of production of goods or services
| - Decisions to achieve certain objectives are taken as given, the problem is how best to achieve them
56
What is allocative efficiency?
- Production of most desired/worthwhile goods and services at the least cost
- Objectives have to compete with each other, the problem is whether (or how many) resources are allocated to achieving each objective
- All about whether to do something or how much of it to do, rather than how to do it
57
What are the two main types of efficiency relevant to healthcare?
- technical
| - allocative
58
What is economic evaluation?
Comparative analysis of courses of action in terms of both costs and consequences
59
What are the four basic steps to economic evaluation?
- identify
- measure
- value
- compare
(the costs and consequences of the alternatives)
60
What is measured in a cost-effectiveness analysis and how are the outcomes valued?
- single common variable
| - natural units (e.g. life years gained / number of people quitting smoking)
61
What is measured in a cost-utility analysis and how are the outcomes valued?
- all effects
| - QALYs (or equivalent)
62
What is measured in a cost-benefit analysis and how are the outcomes valued?
- all effects
| - monetary value (net benefit/loss)
63
What is a cost minimisation analysis?
- health effects of two interventions assumed or known to be equal
- an aid to determining the option with the lowest monetary cost
- cannot provide help when effectiveness differs between interventions
- not a form of full economic evaluation
64
What are the pros and cons of cost-effectiveness analyses?
```
PROS
- straightforward to carry out
CONS
- cannot compare disparate alternatives
- uses a narrow, uni-dimensional measure of outcome when in reality interventions often produce multiple different outcomes
```
65
What are the pros and cons of cost-utility analyses?
PROS
- enables comparison of interventions that would be measured using different clinical outcomes
- enables a global health budget to be allocated more efficiently across different clinical areas
CONS
- heavily reliant on QALY measurements (what if they're actually not a good way of measuring things, or don't produce equitable distribution of resources)
66
What are the pros and cons of cost-benefit analyses?
PROS
- most comprehensive form of evaluation
- takes a societal perspective
- all costs and all outcomes are included
- allows comparison across interventions with different health outcomes
- allows comparisons with non-healthcare interventions (e.g. social care) so can be used to allocate a global budget
CONS
- controversial: how do we assign monetary values to health outcomes? how do you value a life?
- requires uniform valuation across all options to enable efficient allocation of resources: how do you value societal costs e.g. time?
67
What is the preferred form of economic evaluation used to allocate resources in UK healthcare?
Cost-utility analysis
68
What is the most comprehensive form of economic evaluation for healthcare?
Cost-benefit analysis
69
Why can markets not be relied upon to allocate healthcare resources?
Market of healthcare fails on a number of levels:
- "consumers" (patients) rely on "agents" (HCPs) to access the market and help decide what they need from it
- in some situations people other than the consumer (patient) will benefit from the consumer accessing healthcare (e.g. vaccination herd immunity)
- need for healthcare is highly unpredictable
- suppliers cannot enter and leave the market easily
Phase I: H&S
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Decks in class (12)
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